Alcohol Withdrawal

Question 1

What are the signs and symptoms seen in alcohol withdrawal and how soon after a patient’s last drink may they occur?

Answer 1

• Signs and symptoms
  
  • Typically begin 6-24 hours after last drink.
  • Physical: tremor, sweats, nausea.
  • Psychological: insomnia, altered mood, alcoholic hallucinosis.
• Alcohol withdrawal seizures
  
  • Generalized tonic-clonic seizures.
  • 12-48 hours after last drink.
• Alcoholic hallucinosis
  
  • Hallucinations: auditory (e.g. hostile voices), visual (e.g. Lilliputian – things and people seem tiny), tactile (e.g. formication – insects crawling on/under skin).
  • May also have headaches, dizziness, and irritability.
  • 12-24 hours after last drink, resolving by 48 hours.
• Delirium tremens
  
  • 3-7 days after last drink.
  • Delirium, confusion.
  • Tremor and seizures.
  • ↑HR and ↓BP.

Question 2

How is alcohol withdrawal managed?

Answer 2

• ABC, including fluids.
  
  • Monitor symptoms with CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Scale): severe is ≥20.
  • Benzodiazepines PO for seizures and sedation. Chlordiazepoxide or diazepam is 1st line, or oxazepam if there is liver impairment. Lorazepam IV if seizures are ongoing. Barbiturates and ITU if refractory.
  • Nutritional support: thiamine, folate, and correction of any deficiencies in glucose, K+, Mg2+, and PO43-. Consider IV initially as GI absorption impaired.

Question 3

What is the pathophysiology behind Wernicke-Korsakoff Syndrome?

Answer 3

• Neurological syndromes caused by thiamine (vit B1) deficiency.
  
  • Alcohol misuse results in reduced thiamine intake from poor nutrition and impaired GI absorption.

Question 4

Describe Wernicke’s encephalopathy.

Answer 4

• Acute presentation, which may be mistaken for intoxication.
Classic triad (though usually not all are present):
  
  • Ophthalmoplegia: nystagmus, lateral rectus palsy.
  • Ataxia with wide-gait.
  • Confusion

Question 5

Describe Korsakoff’s syndrome.

Answer 5

• Chronic manifestation of thiamine deficiency.
  
  • Anterograde amnesia: can’t form new memories.
  • Retrograde amnesia: can’t remember the past.
  • Confabulation: false memories – believed to be true – to fill the memory blanks.

Question 6

How is Wernicke-Korsakoff managed?

Answer 6

• Thiamine replacement: initially IM or IV as an inpatient, then PO long-term.
  
  • If glucose is given to correct hypoglycaemia in a chronic alcohol user, thiamine must be given concurrently as glucose will deplete remaining thiamine.